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Assessment ch 18
Exam 2
23
Nursing
Undergraduate 3
03/17/2011

Additional Nursing Flashcards

 


 

Cards

Term

 

Anatomy

 

Thorax

Definition
mediastinum-middle section-esophagus, trachea, heart, and great vessels
posterior- c7 to t12
inferior border of the scapula- t7-8
Term

 

Anatomy 

 

Lungs

Definition
Left and right pleural cavities on either side of the mediastinum contain the lungs.

Left lung has 2 lobes, right has 3 separated by fissures, oblique on both and horizontal on right

Borders:
-anterior-
apex- 3-4cm above inner third of clavicles
base-rests on diaphragm at about the 6th rib midclavicular
Laterally-apex of axilla to 7-8th rib
posteriorly-c7 apex, t10 base, base lowers to t12
Term

 

Anatomy

 

Lungs

Definition
Pleurae-form an envelope around the lungs

trachea- begins at cicoid cartilage and lies anterior to the exophagus.
bronchial bifurcation: t4-5

inspiration: flattens diaphragm
expiration: relaxes diaphragm

accessory muscles:
sternomastoid
scaleni
trapezii
intercostal
Term

 

Physiology

 

four functions of the respiratory system

Definition
-supplying oxygen to the body for energy production
-removing carbon dioxide as a waste product of energy reactions
-maintaining homeostasis (acid-base balance) of arterial blood
-maintaining hear exchange
Term

 

control of respirations

Definition
involuntary- brain stem-medulla and pons

humeral regulation
-hypoxemia: decreased o2 level
-hypercapnia: increase co2 level
Term

 

respiratory patterns

Definition
dyspnea
-tachypnea: >24 breaths per min, fever, fear, exercise, pneumonia, lesions in the pons, alkalosis
-bradypnea: <10/min, drug induced respiratory depression in medulla, increased intracranial pressure, diabetic coma
-hyperventilation: increase in rate and depth (blows of co2)diabetic ketoacidosis (kussamauls respiration), hepatic coma, overdose of salicylate, lesion in midbrain
-hypoventilation: irregular and shallow, overdoes of narcotics, anesthetics, prolonged bed rest, splinting
-cheyne-stokes respiration: 30 sec of breathing and 20 sec of apnea, severe heart failure, renal failure, meningitis, drug overdose, increased cranial pressure, normal in infants and aging persons during sleep
-biots respiration: like cheyne-stokes but irregular (cycle can last from 10 sec-1 min), head trauma, brain abscess, heat stroke, spinal meningitis, encephalitis
-chronic obstructive breathing: prolonged expiration, COPD
Term

 

Subjective data

Definition
cough:productive, dry, blood, odor, severity
-description(hacking, congested, dry, barking, what makes it better/worse

shortness of breath: with chest pain(stabbing, burning, constant), time of day, better/worse, accompanying side effects

orthopnea: difficulty breathing when supine (pillows)
paroxysmal nocturnal dyspnea
history of pulmonary disease
history of respiratory infections
smoking history
environmental factors
self care behaviors
Term

 

coughs

Definition
respiratory infections-continuous throughout the day-acute illness
irritants- afternoon/evening
postnasal drip- night
chronic bronchial inflammation of smokers- early morning
chronic bronchitis- productive cough for 3 months of the year for 2 years in a row
Term

 

objective data

 

inspection

Definition
anterior chest
-inspect:
skin color and condition: cyanosis, pallor of lips and nails
symmetry
facial expression: relaxed, unconscious breathing effort
level of consciousness: alert and cooperative
quality of respirations
position
rib interspaces: retractions, bulges
accessory muscles (scalene, sternomastoid, trapezius)
shape and configuration of chest wall

posterior
-inspect:
skin
symmetry
anteroposterior:transverse diameter 1:2
Term

 

palpatation

Definition
anterior
-symmetric chest expansion
-lumps and tenderness
-tactile fremitus

posterior
-symmetric expansion
-spinous processes
-tactile fremitus
-tenderness, moisture, temperature, masses, lesions and crepitus
Term

 

symmetric chest expansion

Definition
place hands on chest:
posterior t9-10
anterior costal margins

slide hands medially to pinch up small fold of skin

unequal occurs with marked atelectasis or pneumonia, thoracic trauma or with pneumothorax
Term

 

tactile fermitus

Definition
a palpable vibration- using palmar base or ulnar edge of one hand touch persons chest while they repeat the words "99

decreased fremitus-anything obstructs transmission of vibrations. obstructed bronchus, pleural effusion or thickening, pneumothorax or emphysema

increased fremitus- compression or consolidation of lung tissue. lobar pneumonia.

rhonchal fremitus- palpable with thick bronchial secretions

pleural friction fremitus- palpable with inflammation of the pleura
Term

 

Percussion

Definition
resonance- the low-pitched, clear, hollow sound that predominates in healthy lung tissue in the adult
hyperresonance-lower-pitched, booming sound found when too much air is present, as in emphysema or pneumothorax
dull-soft, muffled thud, signals abnormal lung density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor
percussion sets into motion the outer 5-7 cm of tissue and abnormality needs to be 2-3 cm wide
Anterior
-predominant note over lung fields
-borders of cardiac dullness
posterior
-predominant note over lung fields; shoulders, interspaces, 5cm intervals
-diaphragmatic excursion-
Term

 

Auscultation

 

normal breath sounds

Definition
bronchial (tracheal)-high, loud, inspration < expiration, harsh, hollow tubular...trachea and larynx

bronchovesicular- moderate, inspiration = expiration, mixed quality, over major bronchi

vesicular- low, soft, inspiration > expiration, rustling, over peripheral lung fields where air flows through smaller bronchioles
Term

 

 

auscultation

Definition
compare bilaterally
-anterior 4
-lateral 5
-posterior 6

decreased or absent breath sounds-obstruction
increased breath sounds
Term

 adventitious lung sounds

 

Definition
-crackles fine(rales)-high pitched short crackling, popping, deflated airways, inspiratory, pneumonia, heart failure, fibrosis, chronic bronchitis, asthma, emphysea
-crackles course- loud, low-pitch, bubbling gurgling-like opening velcro, pneumonia, pulmonary edema, fibrosis, depressed cough reflex
-pleural friction rub- a very superficial sound, coarse and low pitched, as if two pieces of leather rubbed together, both inspiratory and expiratory, when pleurae become inflamed and lose their normal lubricating fluid, pleuritis
Term

 

continuous sounds

 

connected musical sounds

 

Definition
-wheeze- sibilant: high pitched, musical squeaking, polyphonic (narrowed passageways), predominant in expiration, acute asthma, chronic emphysema
-wheeze- sonorous rhonchi: low pitched, musical snoring, predominant in expiration, may clear with coughing, bronchitis, single bronchus obstruction-tumor
-stridor- high-pitched, crowing sound, monophonic, (upper airway swelling obstruction, foreign body), inspiratory, originates in larynx and trachea (louder in neck than chest, croup, acute epiglottitis
Term

 

voice sounds

Definition
bronchophony: "99" normal: muffled, density: clear
egophony: normal "eeee" consolidation "aaaa"
whispered pectoriloquy: "one-two-three" normal-faint or muffled, consolidation- clear
Term

 

pneumothorax

Definition
free air in pleural space
-spontanious, trauma, or tension
inspection
-deviated trachea
-unequal chest expansion
-cyanosis
palpatation
-tactile fremitus-decreased or absent
percussion
-hyperressonant
auscultation
-absent breath sounds
Term

 

measurement of pulmonary function status

 

Definition
-forced expiratory time-number of seconds it takes for the person to exhale from total lung capacity to residual volume, 6 sec or more occurs with obstructive lung disease
-pulse oximeter- 97-98% normal
Term

 

summary checklist:

thorax and lung exam

Definition
-inspection
thoracic cage
respirations
skin color and condition
person's position
facial expression
level of consciousness
-palpation
confirm symmetric expansion
tactile fremitus
detect any lumps, masses, tenderness
-percussion
percuss over lung fields
estimate diaphragmatic excursion
-auscultation
assess normal breath sounds
note any abnormal breath sounds
if so, perform bronchophony, whispered pectoriloquy, egophony
note any adventitious sounds
Term

 

pectus excavatum

Definition
markedly sunken sternum and adjacent cartilages
Term

 

pectus carinatum

Definition
a forward protrusion of the sternum, with ribs sloping back at either side and vertical depressions along costochondral junctions
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